TEST BANK
Ackley and Ladwig’s Nursing Diagnosis
Handbook: An Evidence-Based Guide to
Planning Care
13th Edition, Makic
TEST BANK
,Chapter 01: Anxiety
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning
Care 13th Edition, (2024) Test Bank
Multiple Choice
1. A client presents to the urgent care clinic complaining of a feeling of unease and anxiety
without a known cause. While conducting the assessment, what other finding should the nurse be
most alert for?
a. Excessive salivation
b. Diabetes
c. Diarrhea
d. Heart failure
Answer: C
Diarrhea is a common manifestation of anxiety resulting from activation of the sympathetic
nervous system. The other assessment findings are not related to anxiety.
DIF: Cognitive Level: Knowledge/Remembering TOP: Nursing Process: Assessment
MSC: Psychosocial Integrity
2. A nurse has provided discharge teaching to a client with moderate anxiety. Which statement
by the client indicates the teaching has been effective?
a. “It’s OK to have 1-2 drinks a day to help relieve my anxiety.”
b. “I can double my medications if I feel really anxious sometimes.”
c. “If I practice my breathing exercises, I will never be anxious again.”
d. “I will keep the phone number for the anxiety hotline with me.”
Answer: D
The use of appropriate community resources is an important teaching topic for the client with
anxiety. Breathing exercises may help but will not “cure” the client. Doubling medications on
one’s own can be dangerous and is not advised. Drinking, or using other substances to relieve
anxiety, is not recommended and can lead to substance misuse.
DIF: Cognitive Level: Comprehension/Understanding TOP: Nursing Process: Evaluation
MSC: Psychosocial Integrity
3. The nurse’s aide is taking vital signs on a client admitted with severe anxiety. The aide reports
a blood pressure of 90/58 mm
Hg, a pulse of 56 beats per minute, and respirations of 10 breaths per minute. Which statement
by the nurse is most accurate?
a. “Vital signs do not give accurate information about anxiety.”
,b. “Lowered blood pressure and pulse can be a sign of anxiety.”
c. “If he were anxious, his blood pressure would be sky-high.”
d. “The client must be less anxious than previously.”
Answer: B
Defining characteristics for this diagnosis include changes in vital signs from either sympathetic
or parasympathetic input. A lowered blood pressure and pulse result from parasympathetic input.
DIF: Cognitive Level: Knowledge/Remembering TOP: Integrated Process: Communication
and Documentation
MSC: Psychosocial Integrity
4. Which of the following does the nurse understand about anxiety?
a. The client always knows the source of the anxiety.
b. There are no physical manifestations of anxiety.
c. Often the source of the anxiety is not known to the client.
d. The client never knows the source of the anxiety.
Answer: C
The source of a client’s anxiety may not be known to the client and results in a vague, uneasy
sense of dread that is hard to pinpoint.
DIF: Cognitive Level: Knowledge/Remembering TOP: Nursing Process: Assessment
MSC: Psychosocial Integrity
5. A client presents to the emergency department with symptoms of severe anxiety. Which
question or statement by the nurse would be most important?
“Have you been using alcohol or other drugs recently?”
“You look fine to me. Why are you so anxious?”
“Does anyone else in your family have anxiety?”
“What problems are you having in your life right now?”
Answer: A
Withdrawal from cigarettes, alcohol, or other drugs can precipitate anxiety. A family history may
be contributory but should not be prioritized before the possibility of withdrawal. Telling a client
that he or she looks fine is patronizing and minimizes the client’s concerns, while asking the
client “why” presents a communication block asking the client about problems may not yield a
useful answer as the cause of anxiety is often unknown.
DIF: Cognitive Level: Application/Applying TOP: Nursing Process: Assessment
MSC: Psychosocial Integrity
, Chapter 02: Bathing Self Care Deficit
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning
Care 13th Edition, (2024) Test Bank
Multiple Choice
Question 1 of 5
During the assessment of a client with left-sided weakness who is right-hand dominant, the
nurse identifies that the client needs assistance with ambulation. Which of the following would
be the most relevant defining characteristic for the nursing diagnosis of bathing self-care deficit
in this client?
a) Inability to regulate bath water
b) Inability to access bathroom
c) Inability to dry body
d) Inability to wash body
Correct
c) Inability to access bathroom
This client has a mobility limitation and requires assistance to ambulate, which limits his or her
ability to access the bathroom without assistance. Since the client’s weak side is not the
dominant side, washing and drying should not be a problem. There is no information about
cognitive or fine motor skill deficits that would lead to an inability to regulate water
temperature.
DIF: Cognitive Level: Analysis/Analyzing
TOP: Nursing Process: Diagnosis
MSC: Physiological Integrity: Basic Care and Comfort
Question 2 of 5
The nurse is developing a plan of care for a client who has left-sided weakness. Since there is
only a tub for bathing in the home, the nurse recognizes that there is a bathing self-care deficit
related to which of the following?
a) Environmental barriers
b) Severe anxiety
c) Inability to perceive body part
d) Inability to perceive spatial relationships
Ackley and Ladwig’s Nursing Diagnosis
Handbook: An Evidence-Based Guide to
Planning Care
13th Edition, Makic
TEST BANK
,Chapter 01: Anxiety
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning
Care 13th Edition, (2024) Test Bank
Multiple Choice
1. A client presents to the urgent care clinic complaining of a feeling of unease and anxiety
without a known cause. While conducting the assessment, what other finding should the nurse be
most alert for?
a. Excessive salivation
b. Diabetes
c. Diarrhea
d. Heart failure
Answer: C
Diarrhea is a common manifestation of anxiety resulting from activation of the sympathetic
nervous system. The other assessment findings are not related to anxiety.
DIF: Cognitive Level: Knowledge/Remembering TOP: Nursing Process: Assessment
MSC: Psychosocial Integrity
2. A nurse has provided discharge teaching to a client with moderate anxiety. Which statement
by the client indicates the teaching has been effective?
a. “It’s OK to have 1-2 drinks a day to help relieve my anxiety.”
b. “I can double my medications if I feel really anxious sometimes.”
c. “If I practice my breathing exercises, I will never be anxious again.”
d. “I will keep the phone number for the anxiety hotline with me.”
Answer: D
The use of appropriate community resources is an important teaching topic for the client with
anxiety. Breathing exercises may help but will not “cure” the client. Doubling medications on
one’s own can be dangerous and is not advised. Drinking, or using other substances to relieve
anxiety, is not recommended and can lead to substance misuse.
DIF: Cognitive Level: Comprehension/Understanding TOP: Nursing Process: Evaluation
MSC: Psychosocial Integrity
3. The nurse’s aide is taking vital signs on a client admitted with severe anxiety. The aide reports
a blood pressure of 90/58 mm
Hg, a pulse of 56 beats per minute, and respirations of 10 breaths per minute. Which statement
by the nurse is most accurate?
a. “Vital signs do not give accurate information about anxiety.”
,b. “Lowered blood pressure and pulse can be a sign of anxiety.”
c. “If he were anxious, his blood pressure would be sky-high.”
d. “The client must be less anxious than previously.”
Answer: B
Defining characteristics for this diagnosis include changes in vital signs from either sympathetic
or parasympathetic input. A lowered blood pressure and pulse result from parasympathetic input.
DIF: Cognitive Level: Knowledge/Remembering TOP: Integrated Process: Communication
and Documentation
MSC: Psychosocial Integrity
4. Which of the following does the nurse understand about anxiety?
a. The client always knows the source of the anxiety.
b. There are no physical manifestations of anxiety.
c. Often the source of the anxiety is not known to the client.
d. The client never knows the source of the anxiety.
Answer: C
The source of a client’s anxiety may not be known to the client and results in a vague, uneasy
sense of dread that is hard to pinpoint.
DIF: Cognitive Level: Knowledge/Remembering TOP: Nursing Process: Assessment
MSC: Psychosocial Integrity
5. A client presents to the emergency department with symptoms of severe anxiety. Which
question or statement by the nurse would be most important?
“Have you been using alcohol or other drugs recently?”
“You look fine to me. Why are you so anxious?”
“Does anyone else in your family have anxiety?”
“What problems are you having in your life right now?”
Answer: A
Withdrawal from cigarettes, alcohol, or other drugs can precipitate anxiety. A family history may
be contributory but should not be prioritized before the possibility of withdrawal. Telling a client
that he or she looks fine is patronizing and minimizes the client’s concerns, while asking the
client “why” presents a communication block asking the client about problems may not yield a
useful answer as the cause of anxiety is often unknown.
DIF: Cognitive Level: Application/Applying TOP: Nursing Process: Assessment
MSC: Psychosocial Integrity
, Chapter 02: Bathing Self Care Deficit
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning
Care 13th Edition, (2024) Test Bank
Multiple Choice
Question 1 of 5
During the assessment of a client with left-sided weakness who is right-hand dominant, the
nurse identifies that the client needs assistance with ambulation. Which of the following would
be the most relevant defining characteristic for the nursing diagnosis of bathing self-care deficit
in this client?
a) Inability to regulate bath water
b) Inability to access bathroom
c) Inability to dry body
d) Inability to wash body
Correct
c) Inability to access bathroom
This client has a mobility limitation and requires assistance to ambulate, which limits his or her
ability to access the bathroom without assistance. Since the client’s weak side is not the
dominant side, washing and drying should not be a problem. There is no information about
cognitive or fine motor skill deficits that would lead to an inability to regulate water
temperature.
DIF: Cognitive Level: Analysis/Analyzing
TOP: Nursing Process: Diagnosis
MSC: Physiological Integrity: Basic Care and Comfort
Question 2 of 5
The nurse is developing a plan of care for a client who has left-sided weakness. Since there is
only a tub for bathing in the home, the nurse recognizes that there is a bathing self-care deficit
related to which of the following?
a) Environmental barriers
b) Severe anxiety
c) Inability to perceive body part
d) Inability to perceive spatial relationships
